Medicare Compliance & Reimbursement

Watch out for these hard-to-detect nuances when billing new patient visits.

Make sure you’re aware of the differences between coding for a new patient and an established one or your practice’s bottom line could take a serious hit. Don’t make the same mistake that this practice did when reporting E/M services, outlined in the example provided below.

Code reported: 99201

Chief complaint: Left shoulder pain.

HPI: This 66-year-old female patient complains of left aching, sharp shoulder pain that has been of moderate severity for the past four weeks. It is most severe in the evenings before she goes to bed, and is especially painful when she reaches above her head. Nothing seems to help, including lying down or taking Tylenol. She has no numbness, tingling, swelling, or radiation down the arm.

PMFSH: The patient has had no previous shoulder issues and has never had surgery, but she did have a left side broken clavicle last year. Her mother died of melanoma and her father died of congestive heart failure. She is a retired teacher and swims occasionally but does not practice other exercise regimen. She has no allergies to food or medications. She takes a multi-vitamin every morning but is on no other medication.

ROS: Patient reports no back pain and no swelling in the extremities.

Physical Exam

Constitutional: Healthy-appearing and NAD.

Shoulders: No misalignment left or right. Bony palpation right: Crepitus of right shoulder. Bony palpation left: No tenderness of the clavicle, the acromioclavicular joint, or the greater tuberosity. Tenderness of the scapula; crepitus of left shoulder. Soft tissue palpation left: Tenderness of the supraspinatus. Active range of motion right: Normal. Active range of motion left: Normal but pain is experienced with ROM.

Assessment/Plan: Discussed with the patient the fact that she may have reduced range of motion in her left shoulder due to having held her left side still while her collar bone was healing. Diagnosed her with pain in joint; shoulder region (719.41). Physical therapy shoulder referral. Prescription for Zipsor 25 mg capsule; take 1 capsule four times a day by oral route for 10 days.

Did You Spot the Problems?

Unfortunately, this chart was undercoded for this new patient since the chart qualifies for reporting 99203. This resulted in the practice shortchanging itself to the tune of $65.00 (99201 pays about $43 and 99203 reimburses approximately $108). The visit’s detailed history and physical, along with the low medical decision-making, justify billing 99203. Although $65.00 may not sound like a lot to throw out the window, consider the fact that coding just three of these visits a week incorrectly adds up to over $10,000 per year.

99201 vs. 99203 Primer: Check out the following examples of a rash to help you differentiate between 99201, 99202, and 99203. Remember that new patient visits require you to meet all three key components of history, exam, and medical decision-making:

1. Level one: 99201. The simplest new patient visit is coded 99201 (office or other outpatient visit for the evaluation and management of a new patient ...). A new patient visit covered by 99201 encompasses a limited problem, examination and treatment. For example, a 13-year-old male comes to a pediatrician with symptoms of a rash on his arm, which is diagnosed as a heat rash with no medication prescribed. This represents straightforward medical decision-making — the treatment option is self-limiting or minor, the amount of data reviewed was limited, and the risk to the patient was minimal.

2. Level two: 99202. Using a rash again to demonstrate a visit that qualifies for 99202, this visit involves a patient who presents with a contact rash diagnosed as contact dermatitis. This patient is prescribed a topical steroid cream and the physician reports 99202.

3. Level three: 99203. The patient presents with a diffuse, red sandpaper-like rash as well as an associated sore throat and fever. The pediatrician diagnoses the patient with scarlet fever. In addition, a rapid strep test is performed and is shown as positive, and the patient is treated with antibiotics.